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• W4387158064 abstract "Up to 10% of neonates require positive pressure ventilation (PPV) after birth.1 Airway obstruction (AO) occurs in more than 60% during mask ventilation2 and has been associated with intubation.3 Malposition of the head during mask ventilation has been discussed as a contributing factor for AO. Resuscitation guidelines recommend the sniffing position to avoid AO, even though the effect of head position on efficient mask ventilation has not been determined. This prospective observational pilot study was carried out at the Tuebingen University Children's Hospital, Germany, from 1 August 2019 to 30 April 2021. It aimed to determine head position during mask ventilation immediately after birth, its variation between operators and its potential association with AO. It was approved by the University's Institutional Ethics Committee (number 403/2019BO1) and registered with the German Clinical Trials Register (DRKS00018948). Parents provided written informed consent. A sagittally positioned LifeCam digital camera (Microsoft Corp) recorded the head position with each PPV inflation, using four angle categories (Figure 1). These were as follows: hyperflexion (<85°), sniffing (85–95°), hyperextended (>95°) and unknown head position.4 Positive pressure ventilation was performed, following national guidelines, with the Stephan© ventilator (Fritz Stephan Medizintechnik, Gackenbach, Germany). The New Life Box acquisition system© (Advanced Life Diagnostics UG, Weener, Germany) detected flow and pressure and the breath-by-breath analysis used Pulmochart software, version 5.0. Leaks were calculated using 100 × VTi − VTe VTi $$ 100times left(frac{VTi- VTe}{VTi}right) $$ . Airway obstruction was an end-tidal volume of <2 mL/kg in inflations with mask leaks of <30%.2 Correlations were analysed using Spearman's rank correlation coefficient. The association between head position and AO was assessed using binary logistical regression analysis with repeated measurements. Significance was not defined for this exploratory, hypothesis-generating analysis. We recruited 45 neonates with a median and interquartile (IQR) gestational age of 33 + 6 (31 + 1–37 + 3) weeks/days and birthweight of 1830 (1360–2900) grams. Data on 6278 inflations were analysed, with a median (IQR) of 113 (38–195) inflations per infant. Most (80%) infants were breathing before PPV. Angle δ was visible in 87% during 47% of inflations. Most (97%) unknown head positions were due to external factors, such as covered the necessary landmarks. The median (IQR) infants' head position during PPV was 94° (86–99)°; 91.0° (79–96)° in 14 term; and 95° (85–101)° in 14 very preterm infants born at <32 weeks. The median (IQR) AO inflations per patient was 8 (2–21) with very preterm infants receiving more (10.5, 4.0–25.0) than term infants (7.0, 1.0–12.0). Binominal logistic regression analysis was carried out after excluding the 47% of inflations with unknown head positions and/or the 42% of mask leaks of ≥30%. Airway obstruction was detected in 13% of the inflations There was no difference in the odds ratio (OR) for AO in the hyperextended than sniffing position (1.2), with a 95% confidence interval (CI) of 0.5–2.9 (p = 0.712), but there were more AO in the hyperextended than hyperflexed position (OR 3.2, 95% CI 1.5–6.7, p = 0.003). Airway obstructions tripled when the head was positioned above 90° than <90° (OR 3.0, 95% CI 1.4–6.3, p = 0.003). The median (IQR) mask leak per patient was 14% (0–61), 7% (0–36) in very preterm infants versus 30% (14–98) in term infants and were matched by higher end-tidal volumes of 2.7 mL/kg (1.5–4.1) and 1.3 mL/kg (0.0–3.5). Greater hyperextension during mask ventilation was associated with the less mask leaks (r = 0.27, p = 0.095). The head position during mask ventilation varied widely among the 15 clinicians with a mean difference of 10° (95% CI: 1.9 to 19.7, p = 0.02), and there were high intra-operator variations in angle δ. We believe this was the first study on head position and AO during mask ventilation immediately after birth. There was an association between AO and a hyperextended head position during mask ventilation, particularly if the head was positioned above 90° and a trend towards more mask leaks in the hyperflexed position. These may both contribute to ineffective mask ventilation. The median number of inflations with AO was lower than in previous studies2, 3 possibly due to different AO definitions,5 as were mask leaks3 possible due to poorly fitting. Considerable variations in clinicians using the sniffing position were confirmed. The strengths were the wide-ranging gestational ages and reduced potential operator bias because 15 clinicians took part. The limitations included the unbalanced number of inflations per infant and different lengths of observation time per angle category. This was minimised by averaging data for each infant and using repeated measurements. The head position was not obvious in 47% of cases, but alternative measurement points would not have helped. A hyperextended head position, especially with an angle above 90°, was associated with increased AO during PPV. Head position during mask ventilation should be regularly re-evaluated. Bianca Haase: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; supervision; visualization; writing – original draft; writing – review and editing. Annalena Koneffke: Data curation; investigation; writing – review and editing. Magnus von Lukowicz: Data curation; investigation; writing – review and editing. Maximilian Gross: Data curation; investigation; writing – review and editing. Kija Mortazawi: Data curation; visualization; writing – review and editing. Christian F. Poets: Funding acquisition; supervision; writing – review and editing. Anette Stauch: Conceptualization; investigation; project administration; resources; software; visualization; writing – review and editing. Laila Springer: Data curation; investigation; methodology; supervision; writing – review and editing. Open Access funding enabled and organized by Projekt DEAL. No external funding. None." @default.
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• W4387158064 date "2023-09-29" @default.
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• W4387158064 title "Hyperextended head position during mask ventilation in neonates may be associated with increased airway obstruction" @default.
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• W4387158064 doi "https://doi.org/10.1111/apa.16983" @default.
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